Please activate JavaScript!
Please install Adobe Flash Player, click here for download
ePaper created 2016-04-19, 11:44:05 | version 1.38.0
| trends & applications tooth extractions 30 ortho 1 2016 ommended that the use of such anaesthetics be lim- itedtolocalinfiltration.Ithasbeenclaimedthatnee- dle contact with a nerve felt by the patient as an electricshockisrelatedtoinjectioninjury.Anobvious explanation is that the pos sibility of mechanical in- jury to the nerve is more likely in the case of multiple repeated attempts at the inferior dental nerve block pro cedure. Therefore, it is crucial that the operator achieve optimal pain control with minimal episodes ofinjectionwithminimaldosesofanaestheticagent. Thesurgeryshouldbeplannedaccordingtothein- formation obtained from the preoperative assess- ment process. The procedure itself should aim to mi- nimisethemanipulationaroundtheIDC.Bothshould includethecarefullyplannedaccess,toothsectioning and elevation techniques. In many scenarios, the ex- tractionofthewholetoothmaycarryanunavoidable riskofinjurytothenerve,thereforeintentionalreten- tion of parts of the tooth was proposed via a planned procedureintroducedaround20yearsagocalledcor- onectomy.Thisistheremovalofthecrownofatooth, leaving the root in situ. It is merely adopted to avoid or minimise damage to the IDN. The rate of compli- cations after coronectomy is comparable to that observed after surgical extraction, except with a sig- nificantly low incidence of injury to the IDN. It should be noted that both sectioning and coro- nectomy can be performed with a shorter incision, as theamountofboneremovalrequiredisminimal,thus minimising the postoperative morbidity. However, it cannot be performed in all cases in which the LM3 is close to the IDC and is certainly contra-indicated when the LM3 is decayed or its roots are associated withapathologyandshouldbeconsideredwithcau- tion in severely inclined mesio-angular and horizon- tal impaction cases. The author does not recommend distal bone removal or retraction of the lingual flap with the intention of protecting the lingual nerve, as these may increase the risk of damaging the lingual nerve. It should be emphasised that incision may not extend beyond the distobuccal aspect of the tooth. Theotherimportantaspectofthedentalextraction procedureisthefuturereplacementofthetoothtobe extracted.Thecurrenttrendoftoothreplacementfor both functional and aesthetic reasons is the place- ment of dental implants. The success of this treat- ment largely depends on the availability of healthy bone in sufficient volume. Therefore, it is crucial for the dental practitioner not to compromise the alveo- larboneduringextractionoftheteeth.Changesinthe alveolar bone ridge after an extraction are inevitable. Afteralldentalextractions,boneheightandwidthal- ways undergo dimensional changes. Bone does not regenerate above the level of the al veolar crest, that is,itsheightwillnotincreaseduringhealing.Thebuc- calplatetendstoshrink,shiftingthecrestofthealve- olarridgelingually,andoftenformsaconcavity.Such changesareproportionaltotheamountoftraumato the soft- and hard-tissue during the extraction. An additional unfavourable change that may take placeistheslowremodellingoftheboneformedtofill up the extraction socket owing to lack of functional stimulation.Thepresenceofpoorlyremodelledalveo- larbonemaycompromisethestabilityandfunctionof thefutureimplant.Furthermore,studiesshowthatthe stripping and elevation of mucoperiosteal tissue pro- duceahighernumberofosteoclastswithinthealveo- lar ridge and hence greater resorption and shrinkage are seen after the classical surgical or the traumatic extraction of teeth. Thepreservationofalveolarboneforfutureimplant placement may be achieved by avoiding unnecessary bone removal and stripping of the periosteum during surgery,aswellasperformingasurgicalalveolarbone preservation procedure. Bone removal can be largely avoidedorminimisedthroughmodificationofthetra ditional extraction technique. Thefirstsuchmodificationistheuseofdentalperi- otomesandluxatomestogentlystriptheperiodontal ligamentfibresandwidenthesocketwithoutcausing cracks or fracture of the cortical plates, as commonly encountered when using dental forceps or the bulky elevators. The use of such gentle instruments also eliminates the need for elevation of mucoperio steal tissue. However, it should be noted that the safe use of these instruments requires adequate training and should be encouraged during undergraduate clinics. Clot stabilisation through light packing of the socket withcollagenspongesmayhelptominimiseclotdis- lodgment, as well as accelerate the healing process and bone regeneration. The second strategy is the alveolar bone preserva- tion procedure. This includes packing the extraction socketwithdifferentfillers,suchasosteoinductiveor osteoconductive materials, like auto genous, natural or synthetic bone grafting materials that support the alveolar socket walls, thus preventing their collapse andshrinkage.Itshouldbenotedthatthisintervention can only slow down the post-extraction changes to improvethesuccessofthedentalimplant,butcannot stop them altogether. Finally, post-extraction care should include an explanation of the healing process and po tential symptoms encountered after such procedures. The prescriptionofmedicationsshouldbelimitedtonon- steroidal anti-inflammatory drugs in most cases and imprudentuseofantibioticsorsocketdressingshould be avoided._ contact Dr Kamis Gaballah Educated in the UK and Ireland, Dr Kamis Gaballah is currently an associate professor and senior specialist in oral and maxillofacial surgery at the Ajman University of Science and Technology in the UnitedArab Emirates.He can be contacted at kamisomfs@yahoo.co.uk. 12016